Provider Demographics
NPI:1548968332
Name:RUBBELKE, NICOLE (LGSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RUBBELKE
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13782 BLUESTEM CT STE 100
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8768
Mailing Address - Country:US
Mailing Address - Phone:218-833-9107
Mailing Address - Fax:
Practice Address - Street 1:13782 BLUESTEM CT STE 100
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8768
Practice Address - Country:US
Practice Address - Phone:218-833-9107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26091104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN47-3503652Medicaid